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      Knowledge, Beliefs and Practices Regarding Antiretroviral Medications for HIV Prevention: Results from a Survey of Healthcare Providers in New England

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          Abstract

          Background

          Antiretroviral treatment for HIV-infection before immunologic decline (early ART) and pre-exposure chemoprophylaxis (PrEP) can prevent HIV transmission, but routine adoption of these practices by clinicians has been limited.

          Methods

          Between September and December 2013, healthcare practitioners affiliated with a regional AIDS Education and Training Center in New England were invited to complete online surveys assessing knowledge, beliefs and practices regarding early ART and PrEP. Multivariable models were utilized to determine characteristics associated with prescribing intentions and practices.

          Results

          Surveys were completed by 184 practitioners. Respondent median age was 44 years, 58% were female, and 82% were white. Among ART-prescribing clinicians (61% of the entire sample), 64% were aware that HIV treatment guidelines from the Department of Health and Human Services recommended early ART, and 69% indicated they would prescribe ART to all HIV-infected patients irrespective of immunologic status. However, 77% of ART-prescribing clinicians would defer ART for patients not ready to initiate treatment. Three-fourths of all respondents were aware of guidance from the U.S. Centers for Disease Control and Prevention recommending PrEP provision, 19% had prescribed PrEP, and 58% of clinicians who had not prescribed PrEP anticipated future prescribing. Practitioners expressed theoretical concerns and perceived practical barriers to prescribing early ART and PrEP. Clinicians with higher percentages of HIV-infected patients (aOR 1.16 per 10% increase in proportion of patients with HIV-infection, 95% CI 1.01–1.34) and infectious diseases specialists (versus primary care physicians; aOR 3.32, 95% CI 0.98–11.2) were more likely to report intentions to prescribe early ART. Higher percentage of HIV-infected patients was also associated with having prescribed PrEP (aOR 1.19, 95% CI 1.06–1.34), whereas female gender (aOR 0.26, 95% CI 0.10–0.71) was associated with having not prescribed PrEP.

          Conclusions

          These findings suggest many clinicians have shifted towards routinely recommending early ART, but not PrEP, so interventions to facilitate PrEP provision are needed.

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          Most cited references19

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          HIV providers' perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study.

          Oral pre-exposure prophylaxis (PrEP) can reduce HIV incidence among at-risk persons. However, for PrEP to have an impact in decreasing HIV incidence, clinicians will need to be willing to prescribe PrEP. HIV specialists are experienced in using antiretroviral medications, and could readily provide PrEP, but may not care for HIV-uninfected patients. Six focus groups with 39 Boston area HIV care providers were conducted (May-June 2012) to assess perceived barriers and facilitators to prescribing PrEP. Participants articulated logistical and theoretical barriers, such as concerns about PrEP effectiveness in real-world settings, potential unintended consequences (e.g., risk disinhibition and medication toxicity), and a belief that PrEP provision would be more feasible in primary care clinics. They identified several facilitators to prescribing PrEP, including patient motivation and normative guidelines. Overall, participants reported limited prescribing intentions. Without interventions to address HIV providers' concerns, implementation of PrEP in HIV clinics may be limited.
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            Physician response to surveys. A review of the literature.

            Physician-specific surveys are a frequently used tool in health services research, but attempts at ensuring adequate response rates are rarely reported. We reviewed literature of survey methodology specific to physician surveys and report those found to be most effective. Studies were identified by searching MEDLINE and PSYCHInfo from 1967 through February 1999. We included all English-language studies that randomized physician survey respondents to an experimental or control group. The authors independently extracted data from 24 studies examining survey methodology of physician-specific surveys. We included Mantel-Haenszel chi-squares comparing treatment groups, if present. If not, these were calculated from study data. Pre-notification of survey recipients, personalizing the survey mailout package, and nonmonetary incentives were not associated with increased response rates. Monetary incentives, the use of stamps on both outgoing and return envelopes, and short questionnaires did increase response rates. Few differences were reported in response rates of phone surveys compared with mail surveys and between the demographics and practice characteristics of early survey respondents and late respondents. We report some simple approaches that may significantly increase response rates of mail surveys. Surprisingly, the response rates of mail surveys of physicians compared favorably with those from telephone and personal interview surveys. Nonresponse bias may be of less concern in physician surveys than in surveys of the general public. Future research steps include specifically testing the more compelling results to allow for better control of confounders.
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              Randomized trial of clinical safety of daily oral tenofovir disoproxil fumarate among HIV-uninfected men who have sex with men in the United States.

              To evaluate the clinical safety of daily tenofovir disoproxil fumarate (TDF) among HIV-negative men who have sex with men. Randomized, double-blind, placebo-controlled trial. Participants were randomized 1:1:1:1 to immediate or delayed study drug (TDF, 300 mg orally per day, or placebo). Four hundred healthy HIV-uninfected men who have sex with men reporting anal sex with another man within the previous 12 months enrolled in Atlanta, Boston, and San Francisco. HIV serostatus, clinical and laboratory adverse events (AEs), adherence (pill count, Medication Event Monitoring System, and self-report), and sexual and other sociobehavioral data were assessed at 3-month intervals for 24 months. Primary outcomes were clinical safety, assessed by incidence of AEs and laboratory abnormalities. Study drug was initiated by 373 (93%) participants (186 TDF and 187 placebo), of whom 325 (87%) completed the final study visit. Of 2428 AEs reported among 334 (90%) participants, 2366 (97%) were mild or moderate in severity. Frequencies of commonly reported AEs did not differ significantly between TDF and placebo arms. In multivariable analyses, back pain was more likely among TDF recipients (P = 0.04); these reports were not associated with documented fractures or other objective findings. There were no grade ≥3 creatinine elevations; grades 1 and 2 creatinine increases were not associated with TDF receipt. Estimated percentage of study drug doses taken was 92% by pill count and 77% by Medication Event Monitoring System. Seven seroconversions occurred: 4 on placebo and 3 among delayed arm participants not yet on study drug. Daily oral TDF was well tolerated, with reasonable adherence. No significant renal concerns were identified.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                6 July 2015
                2015
                : 10
                : 7
                : e0132398
                Affiliations
                [1 ]Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
                [2 ]Harvard Medical School, Boston, Massachusetts, United States of America
                [3 ]The Fenway Institute, Boston, Massachusetts, United States of America
                [4 ]Harvard School of Public Health, Boston, Massachusetts, United States of America
                [5 ]Brown University School of Public Health, Providence, Rhode Island, United States of America
                [6 ]New York University, New York, New York, United States of America
                [7 ]New England AIDS Education and Training Center, Boston, Massachusetts, United States of America
                Centers for Disease Control and Prevention, UNITED STATES
                Author notes

                Competing Interests: Dr. Krakower and Dr. Mayer have conducted research with unrestricted grants from Gilead Sciences (DSK and KHM) and Merck (KHM). This study was partly funded by a Virology Fellows Research Grant from Bristol-Myers Squibb. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors.

                Conceived and designed the experiments: DSK JAM IBW AEK KM DG KHM. Performed the experiments: DSK KM DG KHM. Analyzed the data: DSK CEO KM KHM. Contributed reagents/materials/analysis tools: DSK CEO KM DG. Wrote the paper: DSK CEO JAM IBW AEK KM DG KHM.

                Article
                PONE-D-15-03804
                10.1371/journal.pone.0132398
                4492498
                26146824
                a50c60c3-5f6d-4017-bfb9-f0086d5488e1
                Copyright @ 2015

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                History
                : 26 January 2015
                : 13 June 2015
                Page count
                Figures: 3, Tables: 3, Pages: 15
                Funding
                This study was funded by a Virology Fellows Research Grant from Bristol-Myers Squibb and in part by a grant from the National Institute of Mental Health (NIMH) (K23 MH098795), both to Dr. Krakower. This publication was made possible with help from the Harvard University Center for AIDS Research (CFAR), a National Institutes of Health (NIH) funded program (P30 AI060354), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: National Institute of Allergy and Infectious Diseases, National Cancer Institute, National Institure of Child Health and Human Development, National Heart, Lung and Blood Institute, National Institute on Drug Abuse, NIMH, National Institute on Aging, National Institute of Diabetes and Digestive and Kidney Diseases, National Institute on General Medical Sciences, Fogerty International Center, and Office of AIDS Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Catherine Oldenburg is supported by a National Institute of Drug Abuse T32 NRSA (T32DA0131911). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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